DERMATOLOGY EXIMIUS

POSTPARTUM HEMORRHAGE 2021

E DI L YN QU I LA N G , M D
OBSTETRICAL HEMORRHAGE SURGICAL MANAGEMENT OF UTERINE ATONY
UTERINE ATONY § Uterine artery ligation
§ Most frequent cause of obstetrical hemorrhage § Internal Iliac artery ligation
§ Failure of the uterus to contract sufficiently after delivery § Postpartum hysterectomy-total or subtotal
and to arrest bleeding from vessels at the placental § Uterine compression sutures-B-Lynch method- ischemic
implantation site
necrosis,peritonitis
§ Fundus should be palpated after delivery of the placenta to § Uterine packing-concealed bleeding and infection
confirm that the uterus is well contracted
UTERINE INVERSION
§ Vigorous fundal massage usually prevents hemorrhage
§ Complete uterine inversion after the delivery of the
§ 20 units of Oxytocin in 1 liter of IVF is infused
placenta is almost always due to strong traction of the
RISK FACTORS umbilical cord
§ High parity § May also be due to placenta accreta
§ Overdistended uterus § Management:
§ Labor abnormalities-hyper- or hypotonic labor § Immediate assistance is summoned to include
§ Labor induction or augmentation with prostaglandins or anesthesia
oxytocin § Manually replace the inverted uterus by pushing
§ Prior hx of postpartum hemorrhage up on the fundus along the direction of the long
axis of the vagina
EVALUATION AND MANAGEMENT
§ IVF is rapidly infused
§ Careful inspection done to exclude birth canal lacerations
§ If placenta is still attached,do not remove
§ Inspect the placenta to exclude retained placental placenta until infusion system is operational,relax
fragments the uterus with anesthetics(GA)
§ Uterotonic agents:
§ Routinely given to prevent postpartum bleeding
§ Oxytocin given i.v. or i.m.
§ If still bleeding persists second line treatment is
given
Other Uterotonics
§ Methylergonovine- Methergine may cause hypertension
§ Carboprost tromethamine-prostaglandin F

§ Dinoprostone-prostaglandin E2

§ Misoprostol-synthetic prostaglandin E2
§ Surgical Intervention

§ Uterus cannot be repositioned because of the
BLEEDING UNRESPONSIVE TO UTEROTONIC AGENTS dense constriction ring
§ Bimanual uterine compression § Laparotomy is performed
§ Blood transfusion-whole blood or PRBC
§ Get help from anesthesia UTERINE RUPTURE
§ Secure 2 large bore catheters for IVF w/ Oxytocin, insert in- § Most common cause is the separation of a previous
dwelling foley catheter cesarean hysterotomy scar
§ Rapid infusion of crystalloids § Other predisposing factors
§ With sedation and anesthesia, manually explore the uterine § Previous traumatizing operations or
cavity for placental fragments, lacerations or rupture manipulations
§ Explore the cervix and vagina § Currettage, perforations, myomectomy

Classification
§ Complete uterine rupture
- when all layers of the uterine wall are separated
§ Incomplete-
when the uterine muscle is separated but
the visceral peritoneum is intact, also known as
Uterine Dehiscence

TRANSCRIBERS GROUP 5 1

 DERMATOLOGY EXIMIUS
POSTPARTUM HEMORRHAGE 2021
E DI L YN QU I LA N G , M D

DIAGNOSIS
§ Signs of hypovolemic shock
§ Diaphragmatic irritation causes epigastric or chest pain
§ Nonreassuring fetal heart rate patterns
§ If the presenting part has entered the pelvis with labor, loss
of station may be detected thru i.e.
§ If the fetus is partly or totally extruded from the site of the
rupture, abdominal exam or i.e.can help identify the
presenting part that has moved away from the inlet

§ Traumatic Rupture
§ Blunt trauma to the uterus may cause rupture or
abruptio
§ Internal podalic version and delivery
§ Difficult forceps delivery
§ Unusual fetal enlargement such as hydrocephalus
§ Breech extraction
§ Spontaneous rupture
§ Usually occur in px with high parity
§ *use of oxytocin to augment labor in
multigravidas
-Trial labor to women with high parity with CPD or
abnormal presentation

§ Pathological Anatomy
§ rupture occurs at the thinned out LUS
§ Tear is longitudinal adjacent to the broad
ligament, extending upward to the body of the
uterus or downward through the cervix into the
vagina

Management
Repair
Hysterectomy

TRANSCRIBERS GROUP 5 2